Abstract Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Abstract Introduction: The objective of this study was to identify risk factors for deep sternal wound infection (DSWI) after off-pump coronary artery bypass (OPCAB) grafting surgery. Methods: A total of 8,442 patients undergoing OPCAB from April 1, 2009 to December 31, 2018 were retrospectively analyzed. A total of 956 were eventually enrolled on this study based on our exclusion criteria. All subjects were divided into two groups: group 1 (n=63) - DSWI; group 2 (n=893) - without DSWI. Patients were excluded if they had one of the following: acute coronary syndrome, conversion to OPCAB grafting surgery, redo procedure, concomitant cardiac surgery procedures. Results: The prevalence of body mass index (BMI) ≥40 kg/m2 (7.9% vs. 1.9%, respectively; P=0.01), lower extremity atherosclerotic artery disease (23.8% vs. 7.2%, respectively; P=0.001) and use of bilateral internal thoracic artery (19.5% vs. 2.5%, respectively; P=0.008) was significantly higher in patients with DSWI. The incidence of morbidities, including reoperation for bleeding (26.4% vs. 2.1%, respectively; P<0.001), stroke (4.8% vs. 0.8%, respectively; P=0.02), acute renal failure (7.9% vs. 0.8%, respectively; P=0.001), delirium (7.9% vs. 1.7%, respectively; P=0.008) and blood transfusion (30.6% vs. 9.8%, respectively; P<0.001) was significantly higher in patients with DSWI. Conclusions: A BMI of >40 kg/m2, lower extremity artery disease, use of bilateral internal thoracic artery (BITA) graft, postoperative stroke, sepsis, reoperation due to postoperative complications and blood product requirement significantly increased the risk of sternal infection after OPCAB.

Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Abstract Introduction: Open access (OA) publishing often requires article processing charges (APCs). While OA provides opportunities for broader readership, authors able to afford APCs are more commonly associated with well-funded, high-income country institutions, skewing knowledge dissemination. Here, we evaluate publishing models, OA practices, and APCs in cardiology and cardiac surgery. Methods: The InCites Journal Citation Reports 2019 directory by Clarivate Analytics was searched for “Cardiac and Cardiovascular Systems” journals. Sister journals of included journals were identified. All journals were categorized as predominantly cardiology or cardiac surgery. Publishing models, APCs, and APC waivers were defined for all journals. Results: One hundred sixty-one journals were identified (139 cardiology, 22 cardiac surgery). APCs ranged from $244 to $5,000 ($244-5,000 cardiology; $383-3,300 cardiac surgery), with mean $2,911±891 and median $3,000 (interquartile range [IQR]: $2,500-3,425) across 139 journals with non-zero available APCs ($2,970±890, median $3,000, IQR: $2,573-3,450, cardiology; $2,491±799, median $2,740, IQR: $2,300-3,000, cardiac surgery). Average APCs were $3,307±566 and median $3,250 (IQR: $3,000-3,500) for hybrid journals ($3,344±583, median $3,260, IQR: $3,000-3,690, cardiology; $2,983±221, median $2,975, IQR: $2,780-3,149, cardiac surgery) and $1,997±832 and median $2,100 (IQR: $1,404-2,538) for fully OA journals ($2,039±843, median $2,100, IQR: $1,419-2,604, cardiology; $1,788±805, median $2,000, IQR: $1,475-2,345, cardiac surgery). Waivers were available for 51 (86.4%) fully OA and 37 (37.4%) hybrid journals. Seventeen journals were fully OA without APCs, one journal did not yet release APCs, and four journals were subscription-only. Conclusion: OA publishing is common in cardiology and cardiac surgery with substantial APCs. Waivers remain limited, posing barriers for unfunded and lesser-funded researchers.

Abstract Introduction: This study aims to test the effect of phenytoin as an inhibitor of the process of dystrophic calcification in bovine pericardium and porcine leaflets implanted in the subcutaneous tissue of rats. Methods: Isolated segments of biomaterials were implanted subcutaneously in young rats. The study groups received 500 mg phenytoin per kilogram of diet per day. After 90 days, samples were collected and quantitative calcification assessment by optical microscopy, radiological studies with mammography, and atomic emission spectrometry were performed. Results: Inflammatory reaction was a frequent finding in all groups when analyzed by optical microscopy. The calcium level assessed by atomic absorption spectrophotometry was significantly lower in the study groups using phenytoin compared to the control groups (control bovine pericardium group X=0.254±0.280 µg/mg; study bovine pericardium group X=0.063±0.025 µg/mg; control porcine aortic leaflets group X=0.640±0.226 µg/mg; study porcine aortic leaflets group X=0.056±0.021 µg/mg; P<0.05). Radiologic studies revealed a statistically significant difference between the groups treated with and without phenytoin (not only regarding the bovine pericardium but also the porcine leaflets). Conclusion: The results obtained suggest that phenytoin reduces the calcification process of bovine pericardium segments and porcine aortic leaflets in subdermal implants in rats; also, the incidence of calcification in bovine pericardium grafts was similar to that of porcine aortic leaflets.

Abstract Introduction: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Abstract Introduction: This study aimed to determine the effect of preoperative aspirin administration on early and long-term clinical outcomes in patients suffering from diabetes mellitus (DM) undergoing coronary artery bypass grafting (CABG). Methods: In this observational study, a total of 315 patients were included and grouped according to the time interval between their last aspirin dose and the time of surgery; patients who had been continued aspirin intake with last administered dose ≤ 24-hours before CABG (n=144) and those who had been given the last dose of aspirin between 24 to 48 hours before CABG (n=171). Results: Multivariable analysis showed that the continuation of preoperative aspirin intake ≤ 24 hours before CABG in patients with DM is associated with reduced incidence of 30-day major adverse cardiac and cerebral events (MACCE) (P=0.004) as well as reduced incidence of composite 30-day mortality/MACCE (P=0.012). During mean follow-up of 37±17.5 months, the unadjusted hazard ratio (HR) showed that aspirin ≤ 24 hours prior CABG in patients with DM significantly reduced the incidence of MACCE and composite of mortality/MACCE during follow-up (HR: 0.50; 95% confidence interval [CI]: 0.29-0.87; P=0.014 and HR: 0.61; 95% CI: 0.38-0.97; P=0.039, respectively). However, after propensity score (PS) matching, the PS-adjusted HR showed a non-significant trend towards the reduction of MACCE during follow-up (HR: 0.58; 95% CI: 0.31-1.06; P=0.081). Conclusion: Continuation of preoperative aspirin intake ≤ 24 hours before CABG in patients with DM is associated with reduced incidence of early MACCE, but without significant influence on long-term outcomes.

Abstract Introduction: Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort. Methods: Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports. Results: The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3±8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital. Conclusion: Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.

Abstract Objective: To examine the results of various myocardial revascularization techniques in pediatric patients to better understand the strategies for surgical treatment of coronary artery pathologies. Methods: We analyzed 61 publications dedicated to the indications, methods, and results of coronary bypass surgery in children. Due to the small size of this cohort, case reports are also included in our review. Results: The main indications for coronary bypass grafting in children are Kawasaki disease, myocardial revascularization as a necessary procedure during the congenital cardiac surgery, to manage intraoperative iatrogenic damage to coronary arteries, and homozygous familial hypercholesterolemia. The use of internal thoracic arteries as conduits for coronary bypass grafting in children with Kawasaki disease showed significantly better results in long-term functionality compared to autovenous conduits (87% and 44%, respectively, P<0.001). Acute and late coronary events after arterial switch operation for the transposition of the great arteries, anomalous origin of the left coronary artery from the pulmonary artery, and left main coronary artery atresia are the main congenital heart diseases where surgical correction involves interventions on the coronary arteries. Conclusion: The internal thoracic artery is a reliable and durable conduit that demonstrates proven growth potential in children.

Abstract Objective: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients’ data were collected and analyzed retrospectively. Patients’ risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. Results: The mortality rate was 8.04% (18 patients). The patients’ mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff “1.8” turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. Conclusion: The GAV score applies to our population with high predictive accuracy.

Abstract Objective: To compare the in-hospital outcomes of a right-sided anterolateral minithoracotomy with those of median sternotomy in patients who received a mitral valve replacement (MVR) because of rheumatic mitral valve stenosis (RMS). Methods: This is a retrospective analysis of 128 patients (34% male) with RMS between 2011 and 2015. The median age was 53 years (45; 56). The mean ejection fraction was 58.4±6.3%. All the subjects were divided into two groups - Group 1 contained 78 patients who underwent MVR via minithoracotomy (MT-MVR), while Group 2 contained 50 patients who underwent MVR via median sternotomy (S-MVR). Results: In the MT-MVR group, a mechanical prosthesis was implanted in 72% of cases, while it was implanted in 90% of cases in the S-MVR group (P=0.01). The duration of myocardial ischemia was similar (MT-MVR, 77±24 min; S-MVR, 70±18 min) (P=0.09). However, the cardiopulmonary bypass time was lower in the S-MVR group than in the MT-MVR group (99±24 min and 119±34 min, respectively) (P≤0.001). There was no difference in the duration of mechanical ventilation, intensive care unit stay, and hospitalization period. Postoperative blood loss was lower in the MT-MVR group (P≤0.001) than in the S-MVR group. There are no statistically significant differences in postoperative complications (superficial wound infection, stroke, delirium, pericardial tamponade, pleural puncture, acute kidney insufficiency, and implantation of pacemaker). The overall in-hospital mortality was 3.9% (P=0.6) Conclusion: The minimally invasive approach for RMS is feasible and has an excellent cosmetic effect without increasing the risk of surgical complications.

Abstract In aortic valve disease cases, prosthetic valves have been used for valve replacement, however, these prostheses have inherent problems, and their quality in some countries is lower comparing to new-generation models, causing shorter durability. Aortic valve neocuspidization (AVNeo) has emerged as an option, which can be applied to a wide spectrum of these diseases. Despite the promising results, this procedure is not widely spread among cardiac surgeons yet. We developed a surgical technique combining Bentall and Ozaki procedures to treat patients with concomitant ascending aorta replacement and AVNeo and we describe it in this paper.